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SN COUNTY 0 D <br /> NOTIFICATION OF <br /> OF HAZARHAZAR DOUS WASTE DISCHARGE (1`V' <br /> HEALT^ci & SAFETY CODE 25180.7 <br /> ?. EMERGENCY LEVEL:0 II III <br /> PHS-EH LOG <br /> ( ucle One) <br /> B. SOURCE OF INFORMATION Phone: <br /> Name: <br /> Company: 51 a Ctl D Z 6038 <br /> Address: •0 Phone: (_) <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address, <br /> C. LOCATION AND DATE OF6-D^I-SPH,ARD / .�C� <br /> Location: r County) Circle One <br /> (Best Physical Description) <br /> ripsn) <br /> Date of Discharge: <br /> Date Notified: -/ - 3 Time, <br /> D, RESPONSIBLE PERSON BUS[NES <br /> Name of Business: Telephone: (ZM` 4U3- 02B� <br /> Contact Person: q Z <br /> Physical Address: o� 190:7-6 Z <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances. <br /> �o <br /> F. ACTION TAKEN � <br /> �l <br /> S DISPOSITION D 5/ <br /> d•,� �v,�cu G <br /> EH 22 013 (Rev-4/91) <br />